For many of the estimated 20 million Americans with the condition, varicose veins are ugly and bothersome, not an indication of a medical problem. But for others, they can be the source of aggravating and painful symptoms - throbbing legs that swell, itch or ache. Vascular surgeons recommend treatment for people with such problems, which are an indication that the veins aren't moving blood properly, known as venous reflux. They can also cause more serious complications such as leg ulcers - open sores that don't heal on their own.

"If you don't have symptoms, you don't need anything done," said Dr. Jennifer Heller, director of the Johns Hopkins Vein Center at the hospital system's Bayview campus. "That said, bad venous reflux disease can be a serious condition if left untreated."

Varicose veins are thick and swollen blood vessels, the result of damage that prevents them from keeping blood flowing to the heart and lungs. Veins have tiny valves, like double doors that swing one way, that help blood flow. When the valves don't work, blood pools in the veins and they swell.

They're so common that varicose veins affect half of all people over 50, according to the National Institutes of Health. People who are obese, pregnant or have a family history are most likely to develop them.

In the past decade, techniques using heat energy and tiny catheters to shut down damaged veins have replaced surgery, in which damaged veins would be pulled out of the leg. "It felt as good as it sounds, which is rather unpleasant for the patient," Heller said of vein stripping. "You'd have to be in hospital for several days, with no regular activity for several weeks. There could be bruising and recurrence."

Newer treatments include using a laser to get rid of damaged veins or using sclerotherapy, in which a solution is injected into the vein to make them shrink. New options are also being marketed for spider veins, smaller varicose veins that can be unsightly but aren't considered a medical problem. At Hopkins, a hair-thin needle and radio waves are used to shut down spider veins.

It's a small-scale version of one of the most popular options for treating varicose veins, called radiofrequency ablation. A small incision is made in the varicose vein, then a small tube, or catheter, is inserted into the vein. The end of the tube heats up and closes off the vein.

But vascular surgeons caution that, while effective, the treatments come with risks such as tingling and burns to the skin. In about 1 percent of cases, deep vein blood clots could form, which can be deadly if they move to the lungs. Ultrasounds should be done a few days after even the least invasive procedure to check for such clots, said Dr. Rajabrata Sarkar, chief of vascular surgery at the University of Maryland Medical Center.

"You have a tremendous number of people with varicose veins - almost 1 in 3 Americans. Is that really a disease if so many people are walking around with it?" he said. "But it's certainly something that people, particularly women, will be willing to pay to get rid of. We are a very image-conscious society and an enormous industry has cropped up with doctors who can take a couple of weekend courses and become a self-described specialist."

He recommends that patients educate themselves on the procedures and the risks and shop around for a doctor with a wealth of vascular expertise.

Most insurance companies will cover varicose vein treatment such as ablation, but only after a patient has tried compression stockings - tight hose aimed to increase blood flow, said Dr. Norbert Zemankiewicz, a vascular surgeon at the vein clinic at Northwest Hospital Center.

"First I say, try those, and many patients will say they actually like them," he said. "Then you don't need anything done."

His patient, Deborah Dow, tried that for more than a year with no success. After a day of running around caring for her two small daughters, her legs throbbed.

Dow, 37, of Baltimore, didn't care so much about how her legs looked, and she wasn't wild about the idea of surgery. But after years of pain, she had the ablation procedure last year. Today, she's back to her regular workouts, and the pain is gone.

She began developing varicose veins in her left thigh while pregnant with her first daughter, now 7, and they grew more pronounced and spread to her calf with her second daughter, who is 4. Her mother and grandmother both had varicose veins, and she remembered her mother's vein-stripping surgery as a warning of what not to do.

"It just sounded bad," she said. "And I remember as a little girl, my mother recovering from it. It was long, and she had someone stay with us to help out around the house. I wanted to get on with my life."

Do your veins need treatment? Before you get treatment, vascular experts recommend:

Evaluating your symptoms for pain and swelling, which can indicate a need for therapy.

A judge entered a not guilty plea Tuesday for a suspended Broward Sheriff's deputy accused of shooting a man in the leg during an off-duty confrontation at the Hollywood home the victim shared with his girlfriend.